When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Determine apical pulse rate and rhythm.

Observe color and amount of urine.

Compare muscle strength bilaterally.

Assess strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client's heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.

Choice B reason: This is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client's renal function and fluid balance, but these are not the priority assessments.

Choice C reason: This is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client's neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.

Choice D reason: This is another incorrect intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client's reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.

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Correct Answer is A

Explanation

Choice A reason:Hand hygiene is the foundation of Standard Precautions and the single most effective action to prevent transmission of infectious agents. Performing handwashing or using an alcohol‑based hand rub immediately before preparing or administering an injection removes transient microorganisms acquired from touching surfaces and protects both the client and the environment from contamination

Choice B reason:While wearing gloves during handling and disposal of contaminated sharps is recommended whenever there is potential contact with blood or body fluids, it is a secondary barrier. Reliance on gloves alone is insufficient because gloves can have micro‑perforations and are removed after use, making hand hygiene before and after glove use the priority

Choice C reason: Donning a face mask before administering the medication is not a necessary action to indicate an understanding of standard precautions. A face mask is only required when there is a risk of droplet transmission of infectious agents, such as when caring for a client with respiratory infections. It is not needed for self-administration of medications, unless the medication is aerosolized or nebulized.

Choice D reason: Removing the needle before discarding used syringes is not a safe action to indicate an understanding of standard precautions. It increases the risk of needle-stick injuries and contamination. The needle and syringe should be disposed of as a single unit in a puncture-resistant container.

A. Positive external places B. Emotional reflection C. Motivational phrases D. Tranquil sounds

Correct Answer is A

Explanation

Choice A reason: Positive external places are images of pleasant and relaxing environments that can distract the client from the pain and induce a sense of calmness and well-being. Examples of positive external places are a beach, a garden, or a mountain.

Choice B reason: Emotional reflection is a process of exploring and expressing one's feelings and emotions. It may be helpful for some clients to cope with stress and anxiety, but it is not the best focus for guided imagery for chronic pain. Emotional reflection may trigger negative emotions or memories that can worsen the pain perception.

Choice C reason: Motivational phrases are statements that encourage and inspire the client to achieve a goal or overcome a challenge. They may be useful for some clients to boost their self-confidence and self-efficacy, but they are not the best focus for guided imagery for chronic pain. Motivational phrases may not be effective in reducing the pain intensity or duration.

Choice D reason: Tranquil sounds are noises that create a soothing and peaceful atmosphere. They may be helpful for some clients to relax and fall asleep, but they are not the best focus for guided imagery for chronic pain. Tranquil sounds may not be enough to divert the client's attention from the pain or create a positive emotional state.

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When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

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